A small percentage of patients, usually young men, present with Guillain-Barré syndrome associated with early (not late) HIV infection. Guillain-Barré syndrome is an inflammatory demyelinating polyneuropathy causing symmetrical paralysis and few, if any, sensory symptoms, usually beginning in the lower extremities and progressing upward. The condition becomes especially serious if the thoracic musculature is involved because it may impair respiration. The disorder is thought to be autoimmune in etiology and generally self-limited. Intravenous immunoglobulin and plasmapheresis have been used to shorten the course, but neither treatment has been studied well in HIV-infected individuals.

Symptoms of delirium in HIV illness can be managed effectively with modest dosages of either low-potency antipsychotic agents, such as chlorpromazine at 10 to 25 mg once to three times daily; or with high-potency agents, such as haloperidol (Haldol) at 0.25 mg to 5 mg once to three times daily; or with atypical serotonin-dopamine agonists, including risperidone (Risperdal) at 0.5 mg to 2 mg daily; or olanzapine (Zyprexa) at 10 mg daily. There may well be an increased incidence of extrapyramidal symptoms associated with high-potency typical agents in advanced HIV illness, and patients with underlying HIV-associated dementia appear to be at higher risk for medication-induced movement disorders. For patients who do not respond to low-dosage oral therapy, excellent results have been reported with intravenous (IV) haloperidol given in individual boluses ranging from 2 to 10 mg every hour. Some clinicians have also had good results with a combination of IV haloperidol and lorazepam (Ativan), with an average daily IV dose of less than 50 mg of haloperidol and 10 mg of lorazepam. In general, no serious adverse effects have been noted with more aggressive IV regimens, although nearly half of the patients treated may have extrapyramidal symptoms, and extreme care must be used.

Benzodiazepines alone (e.g., lorazepam) do not appear to be effective in delirious states, and they may accentuate confusion.

Studies based on coroners’ reports suggest that patients with advanced HIV disease have a 30-fold increased risk of committing suicide compared with seronegative persons matched for age and social position. Some survey reports indicate that seronegative persons who are in a high-risk group for HIV infection, as well as seropositive persons at all stages of HIV infection, have an elevated lifetime prevalence of suicidal ideation and suicide attempt compared with community control subjects. It is important to note that both sources of data suggest that psychiatric disorder is strongly implicated in suicide, attempted suicide, and suicidal ideation. Psychological autopsies from coroners’ cases have identified psychiatric histories in almost 50 percent of the cases. Suicide attempt and suicidal ideation are correlated with histories of major depressive disorder or substance-related disorders, and in more than half of the cases, these suicidal behaviors commenced before the likely date of seroconversion. Conflicts about sexual orientation may be associated with suicide attempts by adolescents. This, together with the increase in HIV infection in adolescents, may place HIV-infected youths at particularly high risk. Suicide rates in women are not noted to be elevated, but the epidemic is now just starting to affect large numbers of women, and their greater vulnerability to major depressive disorder may mean that women are at increased risk. Advances in therapy may heighten hope and reduce the risk of suicide. However, those whose hopes are first raised but who then do not respond to or cannot tolerate these agents may require psychotherapeutic intervention.

Among the rheumatologic disorders are arthralgias, myalgias, and arthritides involving large joints of the leg. Patients with HIV-related arthralgias may respond to nonsteroidal antiinflammatory agents, although acetaminophen (Tylenol) should be avoided because it may diminish the metabolism of zidovudine. HIV may also be associated with a polymyositis, which involves pain, weakness, and elevated creatine phosphokinase, along with changes on electromyography indicating a myopathic process. Long-term administration of zidovudine may also produce a myositis that persists when the medication is discontinued. Psychopharmacologic interventions are not of demonstrated efficacy in these states.

Neuropathic pain related to HIV usually presents as a persisting, painful sensorimotor neuropathy with dysesthesia, stocking-glove distribution of sensory loss, diminished distal reflexes, and distal weakness. Similarly, postherpetic neuralgia (herpes zoster radiculitis) may involve pain of the face or trunk. Treatment of neuropathic pain syndromes is usually with low-dosage tricyclic antidepressant agents, such as desipramine or nortriptyline at 10 to 25 mg a day. The typical steady-state dosage is 50 mg a day, although some patients require higher amounts (75 to 100 mg daily). A response often occurs within 1 to 2 weeks, but 4 to 6 weeks of treatment may be necessary before response occurs or another tricyclic agent is chosen. In general, tricyclic antidepressants are more effective than the selective serotonin reuptake inhibitors (SSRIs) for chronic neuropathic pain. Opioid analgesics are also useful. Anticonvulsants such as phenytoin (Dilantin) or carbamazepine (Tegretol), at usual therapeutic concentrations required for seizure management, may also be effective. Postherpetic neuralgia may likewise be treated with topical capsaicin (Dolorac) and may respond to clonazepam at 1 to 5 mg daily.

Finally, studies of acute postoperative pain and chronic cancer pain generally indicate that for conditions in which opiate analgesia is indicated, those medications are often underprescribed or irrationally prescribed in subtherapeutic doses at too extended an interval. The clinician should always be alert to that possibility in advanced HIV disease.

A growing list of agents that act at different points of viral replication has raised for the first time the hope that HIV can be permanently suppressed or actually eradicated from the body.

Antiretroviral agents have many adverse effects, too numerous to describe. Of importance to psychiatrists is that protease inhibitors are metabolized by the hepatic cytochrome P450 oxidase system and can therefore increase levels of certain psychotropic drugs that are similarly metabolized. These include bupropion (Wellbutrin), meperidine (Demerol), various benzodiazepines, and SSRIs. Therefore, prescribing psychotropic drugs to persons taking protease inhibitors must be done with caution. For example, plasma concentrations of alprazolam (Xanax), midazolam (Versed), triazolam (Ilalcion), and zolpidem (Ambien) may be increased, and dosage reduction and careful monitoring may be required to prevent oversedation or other toxic effects. Protease inhibitors have been reported to increase concentrations of bupropion, nefazodone (Serzone), and fluoxetine

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